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[Outline] Zhang Zhongjing said: For recurrence due to exertion after a major illness has subsided, Zhi Shi Zhi Zi Chi Tang (Immature Bitter Orange and Fermented Soybean Decoction) is the primary treatment. If there is retained food stagnation, add Da Huang (Rhubarb Rhizome) in pieces the size of five or six "boqi" chessmen.

[Commentary] Cheng Wuji stated: "Lao" (exertion) refers to physical labor, and "Fu" (recurrence) means re-emergence. This refers to the re-emergence of symptoms after recovery from Shaoyang disease due to physical activity. After the recent recovery from Shaoyang disease, the Qi and Blood have not yet stabilized, and residual heat remains. Physical exertion stirs up this internal heat, which returns to the meridians, causing the disease to recur. There are two types: one caused by external injury due to exertion, and the other by internal injury due to diet. Those suffering from external injury due to exertion are not limited to forcefully shaking the body or carrying heavy loads over long distances; even combing hair and washing can disturb Qi, and worry, sorrow, and anxiety can exhaust the Shen (Spirit), all leading to recurrence, let alone excessive physical use. Those suffering from internal injury due to diet occur because overeating leads to lingering pathogens, and eating meat causes recurrence. The *Neijing* states: "Why do residual symptoms persist after the resolution of heat diseases?" It is because strong eating occurs while heat is intense, and although the disease has declined, heat is still stored. Because grain Qi lingers and combines with residual heat, two Yangs merge, resulting in residual symptoms. The classics state: "If the disease has resolved but slight irritability remains, reducing food intake will lead to healing." The transmission of Shaoyang pathogens proceeds from exterior to interior in a sequence; sweating, vomiting, and purging proceed from mild to severe in degrees. However, recurrence due to exertion is different. When pathogenic factors recur, they must be intercepted immediately, without waiting for transmission. Zhi Shi Zhi Zi Tang induces vomiting; does it require symptoms of deficiency-heat and agitation? Adding Da Huang induces purging; does it require delirium and abdominal fullness? The classics state: "For fever recurring after Shaoyang disease, Xiao Chai Hu Tang (Minor Bupleurum Decoction) is used. If the pulse is floating, resolve via sweating; if the pulse is deep and solid, resolve via purging." This is also to swiftly curb the pathogen. Generally, Shaoyang pathogens enter from the exterior, while those in exertion recurrence emerge from within. Sweating, vomiting, and purging are applied according to appropriateness. Exertion recurrence, dietary recurrence, and various other forms of exhaustion are all treatable. However, death ensues if sexual intercourse occurs post-recovery. If infection occurs through male-female exchange, it is called Yin-Yang Exchange; if one falls ill without such exchange, it is called Female Exertion Recurrence. Because internal True Qi is damaged and external heat pathogens are stirred, with deficient Zheng Qi and abundant Xie Qi, it is considered incurable.

Wei Litong stated: This section further explains that after recovery from Shaoyang disease, Qi and Blood are deficient and emaciated, and residual heat remains. Diet and daily life must be regulated and cautious. Regarding sexual activity, it concerns life and death more critically, so it is not listed here, emphasizing the prohibition even more strongly. Saying "after recovery from major illness" applies to all diseases, not just Shaoyang disease. After recovery, Qi and Blood are inevitably deficient. Any consumption of heart and effort, excessive joy or anger, excessive talking or movement can cause relapse due to exertion. Exertion disturbs already deficient Qi and Blood, and deficiency-exhaustion generates remaining residual heat. When heat pathogens retreat, the disease resolves; when heat pathogens arise, the disease recurs. Thus, we see that pathogens transmitted through Shaoyang meridians are continuous and hard to eradicate, and the deficit of Qi and Blood after Shaoyang disease is difficult to restore through neglect. Extending this logic, it applies to all post-illness conditions.

[Outline] Zhang Zhongjing said: For fever recurring after Shaoyang disease has resolved, Xiao Chai Hu Tang (Minor Bupleurum Decoction) is the primary treatment. If the pulse is floating, resolve via sweating; if the pulse is deep, resolve via purging.

[Commentary] Xu Shuwei said: A patient suffered from Shaoyang disease. After sweating for several days, he had body heat, spontaneous sweating, a wiry and rapid pulse, and an unsettled mind. This was true exertion recurrence. I diagnosed it as caused by mental overexertion. The Heart is the residence of the Shen (Spirit). Since it had not returned to its original state, further exhausting the Shen disrupted Ying and Wei (Nutritive and Defensive Qi). One should tonify the Son (Spleen) of the Heart, benefit Spleen Qi, and relieve exertion, hoping for recovery. I prescribed Bu Pi Tang (Spleen-Tonifying Decoction), assisted by Chai Hu Tang (Bupleurum Decoction) to harmonize. Someone asked: "In deficiency, one tonifies the Mother. Why tonify the Son now?" I replied: "Do you not know the difference between deficiency and exertion? The *Nan Jing* states: 'In deficiency, tonify the Mother; in excess, drain the Son.' Everyone knows deficiency requires tonifying the Mother. The *Qian Jin Fang* states: 'For severe Heart exertion, tonify Spleen Qi. When Spleen is prosperous, it influences the Heart.' To treat deficiency, one tonifies what generates me (Mother), consistent with the meaning of 'the root receives Qi, the branches receive shade.' To treat exertion, one tonifies what assists me (Son), consistent with Xunzi's saying that 'there is no case of a son being rich while the father is poor.' This is why treating deficiency and exertion differs."

Wang Haogu stated: Generally, "Lao" (exertion) implies movement. Movement is not uniform; there are differences in Qi and Blood, interior and exterior. If it is Qi exertion manifested as weakness and lack of spirit, the method should be to slightly lift and raise. If it is Blood or sinew-bone exertion, tonify with formulas like Si Wu Tang (Four Substance Decoction). If it affects the Spleen, which is the Central Pivot internally, regulating the Middle Jiao can cure it. This is a tangible pathology. If only external symptoms are seen, it is called recurrence, not exertion. For example, contracting wind-cold again is such a case.

Wu Shou stated: Exertion recurrence is like a wall soaked by floodwaters; the wall recovers only after the water recedes. One must not provoke it. One should lie quietly and rest to nourish Qi. If rising early to work, Qi and Blood will boil, causing fever.

Yu Chang stated: Fever recurring after resolution is due to residual heat inside, calling forth heat. One must distinguish where the heat lies and not treat generically, thereby damaging the deficient Zheng Qi. If in the half-exterior half-interior, still use Xiao Chai Hu Tang to harmonize; if in the exterior, use sweating; if in the interior, use purging. However, these sweating and purging methods refer to using Zhi Shi Zhi Zi Tang for mild sweating and Zhi Shi Zhi Zi Jia Da Huang Tang for mild purging mentioned in the previous clause.

[Outline] Zhang Zhongjing said: For edema/water accumulation below the waist after recovery from a major illness, Mu Li Ze Xie San (Oyster Shell and Alisma Powder) is the primary treatment.

[Commentary] Yu Chang stated: Water accumulation below the waist causes swelling due to fluid infiltration. The *Jin Gui Yao Lue* states: "For swelling below the waist, promote urination." This is a fixed rule. However, after a major illness, Spleen Earth is exhausted and cannot control water, leading to water overflow. Using this formula for harsh attack seems to ignore the deficiency. Precisely because the water momentum has not invaded the upper half of the body, urgently draining the water preserves much health. If mild agents were used, Yin water would surely invade the Yang realm, making it impossible to drive out later. Quack doctors, encountering post-major illness cases, all use warming and tonifying, thinking it is good, unaware of their great error.

[Outline] Zhang Zhongjing said: For excessive spitting and chronic non-resolution after recovery from a major illness, it indicates Cold in the Stomach. One should warm it with pill medicine, preferably Li Zhong Wan (Regulate the Middle Pill).

[Commentary] Yu Chang stated: Body fluids, congealed by Stomach Cold, become turbid saliva. If unresolved for a long time, the person will become emaciated and withered. Therefore, decoctions for drastic cleansing are not used, but pills for slow action are employed. Li Zhong Wan is an excellent medicine for distinguishing Yin and Yang and warming/tonifying the Spleen and Stomach.

[Outline] Zhang Zhongjing said: After Shaoyang disease resolves, for emaciation, shortness of breath, and rebellious Qi with desire to vomit, Zhu Ye Shi Gao Tang (Bamboo Leaf and Gypsum Decoction) is the primary treatment.

[Commentary] Yu Chang stated: Body fluids are consumed by heat pathogens. Unclear residual heat inevitably leads to emaciation and shortness of breath, making recovery difficult. If accompanied by rebellious Qi and desire to vomit, it means residual pathogens are disturbing fluids again. Thus, this decoction is used to tonify deficiency, clear heat, and descend rebellious Qi.

[Outline] Zhang Zhongjing said: When the patient's pulse has normalized but slight irritability occurs at dusk, it is because the disease has recently resolved, and people force-feed them. The Spleen and Stomach Qi are still weak and cannot digest food, causing slight irritability. Reducing food intake will lead to healing.

[Commentary] Zhu Gong stated: Generally, new recovery often involves food injury, leading to fullness, dry belching with food odor, borborygmus, and diarrhea. One may prescribe Sheng Jiang Xie Xin Tang (Ginger Decoction for Draining the Epigastrium).

Chen Shiduo stated: After Shaoyang fire retreats and pathogens scatter, Stomach Qi begins to turn. At this time, one must avoid feeding hastily. Once fed, Stomach Qi closes and cannot reopen. Even if purgatives are used then, Stomach Qi is severely damaged, and fire pathogens gather again, becoming incurable. It is better to abstain from food, allowing the Middle Jiao to naturally transport and transform, gradually opening and moving without obstruction. Then, use Fu Ling (Poria), Chen Pi (Tangerine Peel), Shan Zhi (Gardenia) each 1 qian, Bai Shao (White Peony Root) 3 qian, Chen Qu (Aged Leaven), Zhi Qiao (Immature Bitter Orange), Hou Po (Magnolia Bark), Gan Cao (Licorice Root) each 0.5 qian, and Mai Ya (Barley Sprout) 2 qian. This formula seems ordinary but regulates naturally without incident. However, it must be taken when hungry. Taking it when full merely increases bloating. After Shaoyang resolution, pathogens have retreated, and Zheng Qi is inherently deficient. Tonification is appropriate. But since Spleen and Stomach are weak, heavy tonics may not be tolerated. The method should use less Stomach-tonifying medicine and more Spleen-tonifying medicine. Especially, one should not use too much Spleen-tonifying medicine and too little Kidney-tonifying medicine. Because the Kidney generates Earth (Spleen), Earth generates Metal (Lung). When Metal is prosperous, Wood (Liver) is restrained and does not attack Spleen Earth. Thus, tonifying the Kidney is precisely to tonify the Spleen. Use Shu Di (Prepared Rehmannia Root) 1 liang, Mai Dong (Ophiopogon Tuber), Bai Shao (White Peony Root), Bai Zhu (Atractylodes Macrocephala Rhizome), Yi Yi Ren (Coix Seed) each 3 qian, Wu Wei Zi (Schisandra Berry) 0.5 qian, Rou Gui (Cinnamon Bark) 0.3 qian, Bai Jie Zi (Mustard Seed) 1 qian. This formula specifically tonifies the Spleen and Kidney meridians. There is no need to tonify all organs generally, yet all organs are benefited.

Pang Anchang stated: For recent recovery, one should first consume thin white rice porridge, then thicker porridge, then mushy porridge. Give in small amounts repeatedly. Do not overconsume meat. For men who engage in sexual activity early after a major illness and fall ill, it is named Female Exertion Recurrence. Symptoms include heavy head unable to lift, visual disturbances, lower back pain, or sudden urgent/cramping pain in the lower abdomen, aversion to cold with fever, occasional surging of Yin Fire causing facial flushing, chest and heart irritability. Huo Ren Ren uses Shu Shi Tang (Mouse Feces Decoction) as primary treatment. For heat, use Zhu Pi Tang (Bamboo Bark Decoction). *Qian Jin Fang* uses Chi Nong San (Red Mud Powder). For the weak, use Ren Shen San Bai Tang (Ginseng Three Whites Decoction) to wash down Chi Yi San (Red Coat Powder). For urgent lower abdominal pain with deep, reversed, and cold pulses, use Dang Gui Si Ni Tang (Angelica Four Reversals Decoction), add Fu Zi (Aconite Lateral Root) and Wu Zhu Yu (Evodia Fruit), and take with Chi Yi San. Also, stir-fry 1 sheng of Wu Zhu Yu with wine and apply hot compress to the lower abdomen. If the testicles retract into the abdomen and the Li Mai (Departing Pulse) appears, death is inevitable and incurable.

Li stated: "Recurrence" means the disease returns to its initial state. After recent recovery, fluids have not restored, and Qi and Blood are still deficient. If combing, washing, speaking, or moving happens too early, or if thinking is excessive, it becomes Exertion Recurrence. Because exertion generates heat, heat takes advantage of deficiency and returns to the meridians, inevitably causing recurrence again. Xiao Chai Hu Tang (Minor Bupleurum Decoction) and Mai Men Dong Tang (Ophiopogon Decoction) should be used to harmonize. For Dietary Recurrence, after recent recovery, Stomach Qi is still weak. If appetite is indulged, digestion fails, leading to fever as described previously. If tonics are used, Stomach heat increases. Treatment requires clearing heat and resolving food stagnation. For mild cases with slight abdominal fullness, reducing food heals itself. For severe cases, vomiting and purging are necessary. Use Zhi Chi Zhi Da Huang Tang (Immature Bitter Orange, Fermented Soybean, and Rhubarb Decoction). For chest fullness, use Sheng Jiang Xie Xin Tang (Ginger Decoction for Draining the Epigastrium). For recurrence due to alcohol, use Huang Lian Jie Du Tang (Coptis Decoction for Resolving Toxicity). For any recurrence syndrome, if the initial illness resolved via sweating on the seventh day, the recurrence will also resolve via sweating on the seventh day. If the initial illness resolved on the fourteenth day, the recurrence will also resolve on the fourteenth day. Even if recurrence happens three or four times, it will resolve after three or four rounds of sweating. However, if Exertion Recurrence persists for a long time without healing, it may develop into Lao Fei (Consumption/Tuberculosis).